Complex Treatment of a High-Energy
Proximal Femur Fracture in a Young Adult – a Case Presentation
Fabian Klein1, Florin Safta1, Daniel Vilcioiu1, Ioan Cristescu1
1 Department III of Orthopedics and Traumatology, Clinical Emer-
gency Hospital, Bucharest, Romania Corresponding author:
Fabian Klein
Department III of Orthopedics and Traumatology, Clinical Emergency Hospital, Bucharest, Romania.
E-mail: fabian.c.klein@gmail.com
Abstract
High energy fractures involving the proximal femur pose diffi culties regarding their treatment, as they are often highly comminuted and associated with other lesions.
We present the case of a 27-year old male patient which was treated for such a fracture over the course of 30 months, including several different implant types. The conclusion of this case focuses on the need of trying to obta- in a more manageable fracture with each surgical procedure in the long term, as well as developing new implants with more suitable biomechanics for such cases.
Keywords: fracture, proximal femur
Rezumat
Fracturile de energie înaltă ce implică femurul proximal adesea pun probleme în ceea ce privește tratamentul, da- torită naturii adesea intens cominutive și a leziunilor asociate în astfel de cazuri. Prezentam cazul unui pacient de 27 de ani și sex masculin, care a urmat tratamente pentru o astfel de fractură timp de 30 de luni, incluzând diferite tipuri de implanturi. Concluziile cazului se axează pe necesitatea obţinerii unui tip de fractură mai ușor de tratat pe termen lung cu fi ecare intervenţie chirurgicală, precum și pe necesitatea creării unor tipuri noi de implant cu propri- etăţi biomecanice mai adaptate unor astfel de cazuri.
Cuvinte cheie: fractură, femur proximal CASE REPORTS
INTRODUCTION
Highly comminutive proximal femur fractures in yo- ung healthy adults often occur after high energy trau- ma, such as traffi c accidents1.
Th e classifi cation of fracture type poses a diffi culty, as highly comminuted fractures don’t necessarily res- pect the anatomical regions of the proximal femur, but rather aff ect the area as a whole2,3.
Treatment of such kind of fractures should always be done in a dedicated trauma centre, as this kind of lesions are associated with other life-threatening con- ditions, due to the high energy involved4.
Given the diversity of fracture types there is cur- rently no standardized procedure of treatment and the surgeons experience and preference often dictate the type of implant and procedure used for osteosynthesis.
Options include intramedullary nailing, bone plates,
external fi xation and functional treatment including continuous trans-osseous traction5,6,7,8.
CASE PRESENTATION
We present the case of a 27-year-old male (G.C.), vic- tim of a motorcycle traffi c accident who was transfer- red to our clinic from a regional hospital. At the time of admission, the patient was hemodynamically stable and after medical imaging examinations the following diagnostics were revealed: Left haemopneumothorax, left anterior arches costal fractures C2, C3, comminuti- ve fracture of the left femur and non-displaced fracture of the left scapula.
Classifi cation of the proximal femur fracture posed diffi culties, as the comminution included both the tro- chanteric and subtrochanteric regions. Th e closest re- lated AO/OTA classifi cation would be a 32-C3.1 type fracture (Figure 1).
Th e patient underwent emergency surgical procedu- res, including closed reduction and internal fi xation of the proximal femur fracture using a Strykerâ Gamma Nailâ 3 420 mm x 11 mm with 125 degrees angulated 110 mm lag screw and 2 distal locking screws (Figure 2).
After a 3-week hospitalization, the patient was trans ferred back to the regional hospital where he continued the rehabilitation program. Th e patient was allowed non-weight-bearing mobilization until 3 months postop.
At the 2-month follow-up, there were no signs of fracture consolidation, so a re-intervention was deci- ded. Th e patient underwent the second surgical proce- dure including debridement of the fracture site, graf- ting with an allograft, open reduction of the medial wedge fragment and stabilization with a cerclage wire (Figure 3).
Figure 1. Initial X-Ray imaging of the left proximal femur fracture.
Figure 2. X-Ray imaging after initial surgery showing the Gamma Nail and fracture fragments.
Figure 3. Postop imaging after re-intervention showing cerclage wire implantation.
Th e patient was discharged at 7 days postop and underwent a rehabilitation program in his hometown, including non-weight-bearing for another 3 months.
At 3-month follow-up, there were some signs of bone healing and the patient was allowed partial wei- ght-bearing for one month with full weight-bearing afterwards.
Th e patient presented again at 9 months after the initial surgery, accusing pain in the left hip after a mi- nor traumatism. X-ray scans revealed a fracture of the Gamma Nail at the lag screw site (Figure 4).
A new surgical procedure was planned in order to replace the damaged implant with a new one. Th e use of a Dynamic Hip Screw was preferred after Gamma Nail failure. After extraction of the centromedullary
nail, the fracture site was debrided once more, the cer- clage wire was removed, the fracture was reduced and stabilized with an 8-hole DHS with a 135-degree an- gulation.
3 and 6 month follow-ups revealed signs of callus formation at the fracture site and the patient was allowed weight-bearing.
Figure 6. X-ray showing DHS failure.
Figure 7. 30 months after fracture.
Figure 4. X-ray scan showing Gamma Nail implant failure at the lag screw site.
Figure 5. X-Ray scan showing hypertrophic callus and breakage of cortex screws in the DHS system.
cided to re-intervene to properly reduce the fragments and to improve the bone stock with debridement and cancellous allografts. Due to the fi brotic lesions at the proximal femur, an anatomical reduction was impossi- ble and it was tried to gather the fragments as much as possible to induce bone healing.
Although there was no satisfactory healing per-pri- mam, it should be noted that from a highly comminu- ted fracture with very displaced fragments, a more sta- ble unifocal non-union in the trochanteric region and a better bone stock for subsequent interventions was obtained by the time the Gamma Nail failed.
Subsequent DHS implantation was preferred to other implants, such as DCS or PFN, in order to use the same lag-screw hole as the Gamma Nail, to preser- ve femoral head vascular support through the neck and to use the higher angulation of the DHS plate 135 vs 125 degrees in the Gamma Nail, to obtain a biomecha- nically more satisfactory femoral neck angle (valgus deformity) to promote compression in the fracture site.
Although the DHS system failed eventually, it promoted bone formation which resulted in a hyper- trophic stable non-union which healed even after im- plant failure.
CONCLUSIONS
High energy proximal femur fractures are very diffi cult to treat even in trauma centres with experienced surgi- cal teams, due to the diversity of fracture patterns and the lack of specifi c implants and procedures. Th erefore, every polytrauma case has its own particularities, which must be taken into consideration during orthopaedic treatment.
Emergency surgery will not always result in satisfac- tory fracture reduction and primary bone healing, but should aim to obtain stabilization by the means of a proper length and alignment of the limb with minimal negative interventions on the bone stock. Also, mini- mally invasive procedures are preferable in this kind of polytrauma patients, in order to allow early mobiliza- tion.
Currently all available implants for the proximal femur focus on load sharing rather than load-bearing, with a negative impact on burst-fractures with large bone defects as in the presented case, because of the lack of suitable biomechanics.
Th e 12 moth follow up X-Ray scans showed screw breakage in 3 cortex screws and a hypertrophic callus (Figure 5). Th e patient was advised to remove the im- plant, but did not comply.
At 18 months after DHS implantation and 27 months after initial surgery, at a control X-Ray scan, breakage of the DHS plate was evident and the patient was once more advised to schedule the removal of the implant (Figure 6).
Th e broken plate was removed from under a hyper- trophic callus and stability of the fracture site was tes- ted, with no evident movement. Initially the use of another centromedullary nail was considered, but due to the lack of blood transfusions and after consulting the anaesthesiology team, the surgeons decided not to use another implant.
At 3-month follow-up after DHS removal and 30 months after initial surgery, the patient was full wei- ght-bearing, pain-free and resumed his normal activity.
Th e X-Ray scans showed further callus formation with no signs of non-union (Figure 7).
DISCUSSION
For polytrauma patients, minimally invasive procedu- res are preferable in order to avoid destabilizing the pa- tient, to minimize surgical risks, such as infection, and to be able to mobilize the patient as early as possible.
Closed reduction and internal fi xation was preferred to an open reduction procedure in this case, because of the high-energy nature of the traumatism, to preser- ve remaining vascular support and to promote healing.
External fi xation was avoided in order to minimize the risk of infection, taking into consideration that surgical trauma was not signifi cantly higher using the intrame- dullary nail.
Th e presented case is of great complexity, because of the number and displacement of fracture fragments which made obtaining a proper reduction very diffi cult by closed means.
Th e fi rst surgical procedure focussed solely on sta- bilizing the fracture and the main fragments. Open reduction and fragment stabilization using a cerclage wire was considered, but fi nally avoided due to the polytraumatic nature of the case.
At the fi rst follow-up visit after surgery, as no signs of bone healing were evident on X-Ray scans, it was de-
orthopedic surgery. Pape HC1, Hildebrand F, Pertschy S, Zel- le B, Garapati R, Grimme K, Krettek C, Reed RL 2nd. J Trau- ma. 2002 Sep;53(3):452-61; discussion 461-2.
5. Long gamma nail in the treatment of subtrochanteric fractures.
Borens, O., Wettstein, M., Kombot, C. et al. Arch Orthop Trauma Surg (2004) 124: 443.
6. Ruff ME, Lubbers LM (1986) Treatment of subtrochanteric frac- tures with a sliding screw-plate device. J Trauma 26:75–80 7. Intramedullary osteosynthesis versus plate osteosynthesis in
subtrochanteric fractures. Burnei, C; Popescu, Gh; Barbu, D; Ca- praru, F. Journal of Medicine and Life; Bucharest 4.4 (Oct-Dec 2011): 324-9.
8. The Use of Modifi ed Neufeld Traction in the Management of Fe- moral Fractures in Polytrauma.
9. Browner, Bruce D. M.D.; Kenzora, John E. M.D.; Edwards, Charles C. M.D. J Trauma. 1981 Sep; 21(9):779-87.
1. Hip Fractures in Adults Younger Than 50 Years of Age Epidemi- ology and Results. Robinson, C. M.; Court-Brown, C. M.; Mcque- en, M. M.; Christie, J. Clinical Orthopaedics & Related Research . 312():238-246, March 1995.
2. Fracture and Dislocation Classifi cation Compendium - 2007:
Orthopaedic Trauma Association Classifi cation, Database and Outcomes Committee. Marsh, J. L.; Slongo, Theddy F.; Agel, Ju- lie; Broderick, J. Scott; Creevey, William; DeCoster, Thomas A.;
Prokuski, Laura; Sirkin, Michael S.; Ziran, Bruce; Henley, Brad;
Audigé, Laurent. Journal of Orthopaedic Trauma . 21(10):S1-S6, November/December 2007.
3. Is there any purpose in classifying subtrochanteric fractures?
The reproduciblity of four classifi cation systems. Guyver, P. M., et al. European Journal of Orthopaedic Surgery and Traumato- logy 24.4 (2014): 513-518.
4. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control
References
